The States Most Likely to Vote on Medicaid Expansion in 2014

Several states have yet to make a decisive choice on Medicaid expansion, and 2014 could be their year.

In 2013 a wave of 25 states expanded Medicaid to childless adults under the Affordable Care Act, either through their legislatures or a simple announcement by their governors. In 2014, what resembled a wave will slow to a trickle, but there will likely be new additions to the program, just as there will be new additions in the years that follow (assuming the health law remains standing). After all, it took 17 years for the last state to sign up for the state-federal insurance program after it became law in 1965.

Here are the states that will most likely take action on Medicaid expansion this year. Whether that action will end with participation in the Affordable Care Act’s most polarizing policy is less certain.

New Hampshire

New Hampshire policymakers have tried to expand Medicaid twice and failed to come up with a compromise, but the fact is that Democrats control significant ground in state government and Republicans within the Senate—where the GOP holds only a two-seat edge—have said they’re committed to finding a solution in the new year.

Democrats control the governor’s mansion and the state house, but they couldn’t get expansion through the legislature during regular session this year, instead compromising on a bipartisan panel to explore the issue and make recommendations. That panel backed expansion, and Gov. Maggie Hassan called for a special session in November to reach an agreement. Negotiations broke down over the extent of privatization, a key Republican demand, but lawmakers are reportedly continuing talks using a Democratic proposal as the starting point. Senate Republican Leader Jeb Bradley says he’s still committed to finding a way.

Pennsylvania

As far as state government goes these days, Pennsylvania is solidly red. But in national elections Pennsylvania has backed President Barack Obama twice, and the state’s Republican governor has pitched a plan to expand Medicaid. Gov. Tom Corbett’s proposal, which would require approval from the Department of Health and Human Services, borrows from Arkansas’ vision of greater privatization and Iowa’s insistence upon charging premiums, but it goes further, requiring people receiving Medicaid to be employed or actively searching for work and for everyone earning more than 50 percent of the federal poverty line to share in the costs of coverage.

That makes some doubt Corbett’s seriousness; the work-search requirement appears illegal and the feds wouldn’t allow Iowa to charge premiums for people earning below 100 percent of the poverty line. All of those facts put the prospects of success in question, but there’s little doubt that Pennsylvania will act in 2014—it’s just that it could be to table expansion until there’s a change in the political winds.

Tennessee

Tennessee is under total Republican control, but unlike other southern states, it has a governor who’s both supportive of expansion in some form and is actively communicating with HHS about an acceptable proposal. Gov. Bill Haslam recently wrote a letter to Secretary Kathleen Sebelius thanking her for the department’s willingness to negotiate a privatized model. Notably, though, Haslam isn’t pushing for the kind of cost-sharing sought by Corbett in Pennsylvania. Haslam asked for “the maximum level permitted [by the Centers for Medicare and Medicaid Services].”

Also unlike other southern states, Haslam appears to have significant public support on his side. A survey conducted last month found 63-percent support for Medicaid expansion in the state. The question is whether any plan will pass the muster of a GOP-dominated legislature. The dynamics of Medicaid expansion are different for statewide officials than for lawmakers representing far narrower and often fiercely partisan interests.

Missouri

Missouri has a Democratic governor but a legislature that is firmly in Republican hands. That sounds like a recipe for inaction, but the state’s business community backs expansion and a respected young Republican lawmaker has a proposal that’s estimated to save the state millions well into the years when federal support narrows to 90 percent of total costs.

Missouri never officially acted on expansion in 2013, instead holding hearings and issuing reports. The legislature returns in 2014, which will likely be a decisive year for expansion in the state.

Utah

There’s little question that Utah will vote on Medicaid expansion in 2014; the issue is how it will vote. Gov. Gary Herbert, a Republican, has said he’ll make a decision in 2014 “in conjunction with the legislature,” which is also under Republican control. Herbert has expressed support for the mission of the program and said “too many Utahns lack access to affordable health care.”